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What moderate GOP senators want in ObamaCare repeal

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What moderate GOP senators want in ObamaCare repeal

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The House managed to narrowly pass its ObamaCare repeal bill by finding a delicate balance between hard-line conservatives and moderates. Now the Senate is looking to achieve the same feat, only with a smaller margin for error.

Senate moderates have already put their markers down on the healthcare issues that concern them the most. Individual senators hold much more power in advancing the health bill than individual House members, and if Senate Republicans can’t find a balance among their caucus, the ObamaCare repeal effort could be doomed.

The Senate will only need 51 votes to pass the bill, but because of their slim majority, Republicans can only afford to lose two votes.

The centrist senators have several major concerns with the House bill, known as the American Health Care Act (AHCA), most notably its changes to Medicaid.

The Affordable Care Act allows states to expand Medicaid coverage to more people, funded mostly by the federal government. So far, 31 states and D.C. have done so.

Even as the healthcare bill was working its way through the House, moderate GOP senators hailing from states that took the Medicaid expansion objected to the proposed cuts to the program.

In early March, Republican Sens. Rob Portman (Ohio), Shelly Moore Capito (W.Va.) Cory Gardner (Colo.) and Lisa Murkowski (R-Alaska) sent a letter to Majority Leader Mitch McConnell (R-Ky.) objecting to the Medicaid cuts in the House bill. “We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” the lawmakers wrote.

The legislation has changed since then, but the Medicaid provisions have been largely left alone. The House bill would undo ObamaCare’s Medicaid expansion by 2020, and would cut over $800 billion from the program.

After the House passed the legislation last week, Portman, Capito and Sen. Dean Heller (R-Nev.) were quick to say they still opposed the bill because of the Medicaid provisions.

Capito on Monday said she would like to see some form of Medicaid expansion remain permanent.

“I have seen a lot benefits to the Medicaid expansion in our state, particularly in the mental health and opioid and drug abuse areas,” Capito told reporters. As for the people who have gained coverage through expansion, Capito said “you can’t just drop them off and wish them good luck. “

Moderates have also objected to the fact that the most recent estimates of an earlier version of the House bill would have resulted in 24 million fewer people having insurance coverage over a decade.

Sen. Bill Cassidy (R-La.) has crafted, along with Collins, a different ObamaCare replacement bill that would allow states to decide whether they want to keep ObamaCare or enact something different.

Cassidy has repeatedly objected to the House version of the legislation because he says it doesn’t fulfill President Trump’s promises to “lower premiums, maintain coverage and protect those with pre-existing conditions.” During a May 8 speech at the American Hospital Association, Cassidy said that while the AHCA may lower premiums, it does so by giving people “terrible coverage.”

Aside from coverage issues, abortion is also likely to cause some headaches in the Senate.

The primary group in the Senate working on the bill includes prominent conservatives like Ted Cruz (R-Texas) and Mike Lee (R-Utah), who are likely to insist that the Senate keep a provision from the House that largely strips Planned Parenthood of funding. But Collins has said any Planned Parenthood language is a non-starter.

Moderates are also likely to insist on making sure language is removed from the House bill that would prohibit the bill’s tax credits from being used to purchase coverage on insurance plans that cover abortion. That could be a major problem for conservatives, especially if the revised bill is to have any chance at passing the House again.

Senate Majority Whip John Cornyn (R-Texas) on Monday acknowledged the balancing act leaders will need to pull off. “Now it’s a question of building consensus within the Republican conference. All 52 Republican senators are going to be part of the process … because we’re going to need everybody.”

Cornyn also said he wasn’t concerned about losing votes if the Planned Parenthood language remained in the bill.

Altarum Institute Urges CMS to Adopt Physician-Focused Payment Models

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http://altarum.org/about/news-and-events/altarum-institute-urges-cms-to-adopt-physician-focused-payment-models

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Altarum Institute joins the debate over whether the Centers for Medicare & Medicaid Services (CMS) should delay expansion of its controversial bundled payment programs, specifically the Comprehensive Care for Joint Replacement (CJR) pilot and the cardiac care bundled payment initiative (also known as the Episode Payment Models, or EPM).

In a column published today in Health Affairs, Altarum Vice President and Director of the Center for Payment Innovation, François de Brantes, argues that CMS should delay and ultimately replace its Bundled Payment for Care Improvement (BPCI) program with a physician-focused model.

De Brantes writes that the BPCI program has five flaws that physician-focused models do not have, and those flaws are serious enough to compromise the successful long-term adoption of bundled payment models, which are critical to reducing health care costs and improving outcomes.

“I applaud CMS’s effort to launch bundled payment models, but the current models they have introduced—the CJR pilot and EPM—are inherently flawed, and unlikely to be successful,” says de Brantes.

The five flaws are outlined in detail in the Health Affairs article and in a public comment letter to CMS from Altarum President and CEO Lincoln Smith. They are summarized below:

Hospital Centricity. Each bundle under the program is triggered by an inpatient stay, and in particular, by a specific Diagnostic Related Group, where there is significant variation in the total costs of episodes. This makes it more difficult to distinguish between warranted and unwarranted variation. Additionally, when regulators force every episode to be triggered by a hospital stay, they prevent physicians from exercising judgement in finding the best site for a given episode.

Lack of severity adjustment. The program does not provide a risk adjustment for patients with more complications. For example, a physician performing a total knee replacement for a patient with a serious heart condition would be paid the same to perform the surgery on a patient without complications. This provides an incentive for providers to favor certain patients over others in an effort to avoid losses.

Encouraging hospitalizations for acute exacerbations. The program includes bundles for patients with an Acute Myocardial Infarction (AMI), providing an incentive to hospitalize a patient with a mild AMI that normally would not require an inpatient stay. This runs counter to the purpose of alternative payment models, which is to encourage better management of patient conditions and reduce the potential for acute events.

Weak ties to quality measures. While hospitals enrolled in the CJR pilot and EPM must report certain quality measures, there are instances in which there are not any thresholds required to receive reconciliation payments. In other words, some could be rewarded for reducing cost relative to the target price, even if quality of care deteriorated.

Moving goalposts. One of the core principles of an effective payment model is to provide clear performance targets. The CJR pilot and EPM adjust the target to reflect changes in national trends, but the new targets are not revealed until at least six months after the performance period. This means participants will not know the standard to which they are being held during any given performance period, potentially encouraging participants to overestimate the probability of losses.

In his public comment letter to CMS Administrator Seema Verma, Altarum President and CEO Lincoln Smith states that “Altarum is a strong advocate of payment bundles and alternative payment models in general, but the proposed mandated models is the wrong approach.” He goes on to encourage CMS to consider a physician-focused model proposed by the American College of Surgeons, which “adjusts for patient severity, ties patient outcomes to gains and losses, enables physicians to exercise judgement in providing the best treatment, and encourages collaboration across disciplines.”

 

PREPARING FOR HEALTH CARE COSTS IN RETIREMENT: AN AMERICA’S HEALTH RANKINGS® ISSUE BRIEF

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http://www.americashealthrankings.org/learn/reports/issue-brief-financial-preparedness

Click to access ahr_issuebrief17.pdf

This issue brief, released in collaboration with United Health Foundation and the Alliance for Aging Research, examines current and future seniors’ readiness for health care costs in retirement. Based on analysis of a recently conducted survey of retired seniors (age 65+) and non-retired adults (age 50-64), as well as data from studies on recommended health care savings targets in retirement, key findings include:

  • Many current and future retirees are at risk of not being able to afford the high costs of health care in retirement;
  • A high percentage of current and future retirees are unsure about how much to save to cover both anticipated as well as unexpected health care costs; and
  • Current and future retirees with retirement savings of $20,000 or less are more likely to be in poor health, have chronic disease, and have lower incomes than those with higher rates of retirement savings.

A Medicare Drug Incentive That Leads to Greater Hospitalizations

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Many studies have demonstrated what economics theory tells us must be true: When consumers have to pay more for their prescriptions, they take fewer drugs. That can be a big problem.

For some conditions — diabetes and asthma, to name a few — certain drugs are necessary to avoid more costly care, like hospitalizations. This simple principle gives rise to a little-recognized problem with Medicare’s prescription drug benefit.

For sicker Medicare beneficiaries, the Harvard economist Amitabh Chandra and colleagues found, increased Medicare hospital spending exceeded any savings from reduced drug prescriptions and doctor’s visits. Consider patients who need a drug but skip it because they feel the co-payment is too high. This could increase hospitalizations and their costs, which would make them worse off than if they’d selected a higher-premium plan with a lower co-payment.

Though just a simplified example, this is analogous to what Medicare stand-alone prescription drug plans do. They achieve lower premiums by raising co-payments. This acts to discourage the use of drugs that would help protect against other, more disruptive and serious health care use, like hospitalization.

Studies show that insurers, many of which are for-profit companies after all, are using such incentives to dissuade high-cost patients from enrolling or using the benefit. There’s evidence this occurs for Medicare’s drug benefit, as well as in the Affordable Care Act’s marketplaces.

 The most popular type of Medicare drug coverage is through a stand-alone prescription drug plan. A stand-alone plan never has to pay for hospital or physician visits — those are covered by traditional Medicare. Another way to get drug benefits from Medicare is through a Medicare Advantage plan that also covers those other forms of health care and is subsidized by the government to do so.

Because of this difference, stand-alone drug plans are less invested than Medicare Advantage plans in keeping people healthy enough to avoid some hospital visits.

A study by the economists Kurt Lavetti, of Ohio State University, and Kosali Simon, of Indiana University, quantifies the cost. Compared with Medicare Advantage plans, stand-alone drug plans charge enrollees about 13 percent more in cost sharing for drugs that are highly likely to help patients avoid an adverse health event within two months. They charge up to 6 percent more for drugs that help avoid adverse health events within a year.

Of course, people have choices about plans. Those who have selected a stand-alone drug plan, as opposed to a Medicare Advantage plan, have done so voluntarily. Why do some make this choice?

One answer is that some people are not comfortable with the more narrow networks Medicare Advantage plans offer, with their fewer choices of doctors and hospitals. By choosing a stand-alone drug plan, they can remain in traditional Medicare, which has an open network.

In addition, consumers are generally more attracted to lower-premium plans than higher ones, even if the difference is exactly made up in co-payments. This may be because premiums are easier to understand than cost sharing. Moreover, premiums reflect a sure loss — you must pay the premium to remain in the plan. A higher co-payment, on the other hand, won’t necessarily lead to a loss because you may not use a service.

The appeal of lower premiums is an incentive for stand-alone drug plans to reduce them and increase co-payments. But that can dissuade those who need medications from filling prescriptions and taking them.

Part of the purpose of Medicare’s drug benefit is to encourage enrollees to take prescription drugs that can keep them out of the hospital. In July 2003, promoting the legislation that created Medicare’s drug benefit, President George W. Bush articulated this point. “Drug coverage under Medicare will allow seniors to replace more expensive surgeries and hospitalizations with less expensive prescription medicine,” he said.

But the design of Medicare’s drug benefit includes stand-alone plans that aren’t liable for hospital costs, so they don’t work as hard to avoid them. Encouraging more beneficiaries into comprehensive plans — through Medicare Advantage — or offering a drug plan as part of traditional Medicare itself would address this limitation.

 

 

Enrollment in a Health Plan with a Tiered Provider Network Decreased Medical Spending by 5 Percent

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http://www.commonwealthfund.org/publications/in-the-literature/2017/may/tiered-provider-network-enrollment?omnicid=EALERT1207817&mid=henrykotula@yahoo.com

Synopsis

Employers and health plans are increasingly using tiered provider networks to steer patients to doctors and hospitals that provide higher-quality care at a lower cost. An analysis of tiered network plans in Massachusetts found that they were associated with a 5 percent decrease in spending—$43.36 less per member per quarter compared with per-member spending in similar plans not offering tiered networks.

The Issue

“Tiered-network benefit designs have the potential to deliver higher value and be a tool that employers and other payers can use to decrease spending in the U.S. health care system.”

In health insurance plans featuring tiered provider networks, providers (e.g., physicians and hospitals) are categorized by the quality and cost of their patient care. Providers with higher quality and lower costs are typically placed in the most-preferred tier rankings. Plans furnish their enrollees with information about providers’ relative value and use financial incentives like lower cost-sharing to steer them to preferred providers. In this Commonwealth Fund–supported study, researchers examined the impact of tiered primary care physician groups and hospitals—offered through Blue Cross Blue Shield of Massachusetts (BCBSMA)—on inpatient care, outpatient care, outpatient radiology, and total health care spending.

Key Findings

  • The tiered network plans offered by BCBSMA were associated with lower total adjusted medical spending of $43.36 per member per quarter relative to enrollee spending in similar plans without a tiered network ($830.07 vs. $873.43). This represents a 5 percent decrease in spending.
  • The tiered network plans were also associated with 4.6 percent lower spending on outpatient care per member per quarter compared with nontiered network plans ($576.89 vs. $604.76) and 6.5 percent lower spending on outpatient radiology ($93.71 vs. $100.23). Savings for inpatient care were not significant.
  • Results were similar when the researchers compared spending only within large-group plans, and only within small-group plans.

The Big Picture

Tiered network plans may be more palatable to consumers than narrow-network plans, the authors say, since they cover care from nonpreferred providers, albeit with higher cost-sharing. These findings also suggest that tiered network plans may be a valuable tool for providers that are under pressure to decrease spending. Provider groups could mirror their referral patterns to match tiered networks.

About the Study

The study population consisted of 184,385 nonelderly enrollees (age 64 and younger) who were enrolled in a Blue Cross Blue Shield of Massachusetts smallor large-group tiered network plan for at least one quarter in 2008–2012 and 927,491 nonelderly enrollees in health plans with matched benefit designs, except for no tiered network, in the same period. Enrollees in the tiered network plans paid different cost-sharing levels depending on the tier ranking of their provider.

The Bottom Line

Tiered provider networks have the potential to reduce overall health care spending.

The countdown is on for the 2017 opening of the new Lucile Packard Children’s Hospital Stanford

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http://www.stanfordchildrens.org/en/about/news/releases/2017/countdown-for-opening-of-new-hospital?source=homepage-banner#.WRIvnTcFKhI.facebook

Lucile Packard Children's Hospital Stanford - New Hospital

More than doubling its current size, the expanded children’s hospital will transform the patient experience through family-centered design and technological innovation, while setting new standards for sustainability in hospital design

Palo Alto, Calif. – Nearly a decade in the making, Lucile Packard Children’s Hospital Stanford announces its countdown to the debut of its new pediatric and obstetric hospital campus, slated to open in December 2017.  With a mission to lead the way in family-centered care, the Packard Children’s expansion will more than double the size of the existing campus by linking the original hospital with a new main building, bringing the total hospital space to measure 844,000 square feet.

“This will be the nation’s most technologically advanced, environmentally sustainable and family-friendly hospital for children and expectant mothers,” said Christopher G. Dawes, chief executive officer. The top-ranked children’s hospital in Northern California is at the center of the Stanford Children’s Health enterprise, which is the largest in the Bay Area exclusively dedicated to pediatric and obstetric care.

The new, 521,000 square foot facility and surrounding 3.5 acres of healing green space and gardens were designed in partnership with patients, families, and every level of hospital staff and faculty to ensure all areas of need were accounted for.

“When my mother founded this hospital, she envisioned a place where children and families could receive truly healing care,” said Susan Packard Orr. “She saw the power that nature had to heal and uplift. I’m proud that we have carried her vision forward, with world-class sustainability and holistic elements throughout the new hospital. Everything we do at this hospital will have an eye to ensuring that generations to come will be healthier.”

The ‘Oracle of Omaha’ Condemns Republican Health Care Bill At Berkshire Meeting

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http://www.npr.org/sections/thetwo-way/2017/05/06/527193477/the-oracle-of-omaha-condemns-republican-health-care-bill-at-berkshire-meeting?utm_content=buffer46568&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

Billionaire investor Warren Buffett fielded questions at the annual shareholders meeting for his company Berkshire Hathaway. He offered thoughts and insights on everything from Republicans voting to repeal Obamacare, to the Wells Fargo scandal, to how artificial intelligence and technology might reshape America. Here are some highlights:

Repealing Obamacare is “a huge tax cut for guys like me”

When asked about the bill Republicans in Congress just voted to pass to repeal and replace Obamacare, Buffett signaled his distaste for a tax cut provision. Obamacare pays for health care for Americans in part by taxing wealthier people. The Republican bill scraps that tax on the wealthy.

And Buffett has apparently done the math here. If the Republican bill had been law last year, he said, “my federal taxes would have gone down 17 percent last year, so it’s a huge tax cut for guys like me.”

“That is in the law that was passed a couple days ago,” he added. “Anybody with $250,000 a year of adjusted gross income and a lot of investment income is going to have a huge tax cut.”

In the past, Buffett has bristled at tax policy that he sees as favoring the wealthy — famously saying it’s not fair that he pays taxes at a lower rate than his secretary.

The medical cost “tapeworm”

Buffett said at the meeting that health care costs have become a bigger issue for American businesses than taxes.

He said if you go back to about 1960, corporate taxes were about 4 percent of GDP and now they’re about 2 percent of GDP. At that time, healthcare was 5 percent of GDP and now it’s 17 percent of GDP. “So when American business talks about taxes strangling our competitiveness,” he said, “they’re talking about something that as a percentage of GDP has gone down from 4 to 2.” Meanwhile, medical costs have exploded. “So medical costs are the tapeworm of American economic competitiveness,” he said.

He argued against the tax system crippling competitiveness “or anything of the sort.” He also noted that other developed countries appear to have found better ways to contain medical costs.

These 50 Health Issues Count as Pre-Existing Conditions

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http://fortune.com/2017/05/04/ahca-pre-existing-conditions/

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The Republican plan to repeal and replace the the Affordable Care Act (ACA), which narrowly passed a vote in the House today, rolls back protections for people with pre-existing conditions, which could increase health care costs for an estimated 130 million Americans.

The American Health Care Act stipulates that states can allow insurers to charge people with pre-existing conditions more for health insurance (which is banned under the ACA) if the states meet certain conditions, such as setting up high-risk insurance pools. Insurers still cannot deny people coverage outright, as was a common practice before the ACA’s passage, but they can hike up premiums to an unaffordable amount, effectively pricing people out of the market.

In fact, premiums could reach as high as $25,700 per year for people in high-risk pools, according to a report from AARP. People who receive insurance through their employer would not be affected, unless they lost their job or moved to the individual insurance market for some other reason.

But what counts as a pre-existing condition? While it depends on the insurer—they have the right to choose what counts as “pre-existing”—these ailments and conditions were universally used to deny people coverage, according to the Kaiser Family Foundation, a nonprofit focusing on health care research.

  • AIDS/HIV
  • Alcohol or drug abuse with recent treatment
  • Alzheimer’s/dementia
  • Anorexia
  • Arthritis
  • Bulimia
  • Cancer
  • Cerebral palsy
  • Congestive heart failure
  • Coronary artery/heart disease, bypass surgery
  • Crohn’s disease
  • Diabetes
  • Epilepsy
  • Hemophilia
  • Hepatitis
  • Kidney disease, renal failure
  • Lupus
  • Mental disorders (including Anxiety, Bipolar Disorder, Depression, Obsessive Compulsive Disorder, Schizophrenia)
  • Multiple sclerosis
  • Muscular dystrophy
  • Obesity
  • Organ transplant
  • Paraplegia
  • Paralysis
  • Parkinson’s disease
  • Pending surgery or hospitalization
  • Pneumocystic pneumonia
  • Pregnancy or expectant parent (includes men)
  • Sleep apnea
  • Stroke
  • Transsexualism

But Cynthia Cox, Kaiser’s associate director, notes that the above list is a conservative sampling of all of the issues and maladies that insurers could count as pre-existing conditions. ” There are plenty of other conditions, even acne or high blood pressure, that could have gotten people denied from some insurers but accepted and charged a higher premium by other insurers” says Cox.

Here are some examples of those other conditions that experts have noted could hike premiums:

  • Acid Reflux
  • Acne
  • Asthma
  • C-Section
  • Celiac Disease
  • Heart burn
  • High cholesterol
  • Hysterectomy
  • Kidney Stones
  • Knee surgery
  • Lyme Disease
  • Migraines
  • Narcolepsy
  • Pacemaker
  • Postpartum depression
  • Seasonal Affective Disorder
  • Seizures
  • “Sexual deviation or disorder”
  • Ulcers

The left-leaning Center for American Progress notes that high blood pressure, behavioral health disorders, high cholesterol, asthma and chronic lung disease, and osteoarthritis and other joint disorders are the most common types of pre-existing conditions.

Just how expensive are pre-existing conditions? A recent report from the Center for American Progress found that insurers could charge people with metastatic cancer as much as $142,650 more for their coverage, a 3,500% increase.